I have reviewed Sugar Land Dental's Notice of Privacy Practices, which explains how my dental/medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

I,   Name , have received a copy of Sugar Land Dental, P.C d/b/a Sugar Land Dental's Notice of Privacy Practices.
I,   Name , would not like to have a copy of Sugar Land Dental, P.C Notice of Privacy Practices. I fully understand Notice of Privacy Practices.

If patient is 18 and over He / She must give a Signed Authorization for parent's to access dental records and payment.
I   Name , have submitted my parent's authorization for dental access.